Overview

Although the divorce rate has stabilized at about 50%, this course will not focus on
unhealthy marriages or factors that contribute to divorce. Rather, the course will focus on
maintaining a healthy marriage and long-term relationships. From a theoretical perspective,
Sternberg identified the components of two types of long-lasting relationships: companionate
or consummate loves. Within the theoretical perspective, the course will highlight specific
communication patterns and affects and the impact that self-care can have in maintaining
healthy, long-term relationships. In addition, the course will also draw attention to
cultural differences in maintaining a healthy marriage, as most relationship research has
focused on majority populations. As such, the course will summarize some of the literature
about populations not typically studied in relationship research. Finally, concrete
implications for mental health professionals working with couples will also be
discussed.

Audience

This course is designed for licensed mental health professionals, including counselors, therapists, and social workers, working with couples or individuals in long-term relationships.

Accreditations & Approvals

NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. NetCE, #1092, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org through the Approved Continuing Education (ACE) Program. NetCE maintains responsibility for the program. ASWB Approval Period: 03/13/2016 to 03/13/2019. Social workers should contact their regulatory board to determine course approval for continuing education credits. NetCE is accredited by the International Association for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.
NetCE SW CPE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #0033.
This course is considered self-study, as defined by the New York State Board for Social Work.
Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.

Designations of Credit

NetCE designates this continuing education activity for 1 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 2 Clinical continuing education clock hours, in accordance with the Association of Social Work Boards. NetCE is authorized by IACET to offer 0.2 CEU(s) for this program.

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190; Texas State Board of Social Worker Examiners, Approval #3011; Texas State Board of Examiners of Professional Counselors, Approval #1121; Texas State Board of Examiners of Marriage and Family Therapists, Approval #425.

Course Objective

The purpose of this course is outline techniques to support and promote a healthy long-term relationship, with the ultimate goal of enhancing clients' clinical experience and marriage.

Learning Objectives

Upon completion of this course, you should be able to:

Compare and contrast different theories of relationships.

Discuss the impact of individual thoughts and affect states in maintaining healthy relationships.

Outline strategies for promoting relational health.

Consider special populations and cultural implications in maintaining healthy relationships.

Faculty

Michael E. Considine, PsyD, LPC, is a licensed professional counselor in New Jersey and Delaware and a New Jersey Certified School Psychologist. He received his PsyD from Chestnut Hill College in Philadelphia, Pennsylvania, in 2009 and his Master's degree from Georgian Court College Graduate School in Lakewood, New Jersey. He works with children of all ages, adults, couples, and families with a wide range of emotional and behavioral issues. As a school psychologist, Dr. Considine also conducts full psycho-educational batteries and has acted as a consultant for parents of children with special needs. Most recently, he has been facilitating trainings and workshops for hospitals and schools. Dr. Considine is currently employed as an independent contractor through Mid Atlantic Behavioral Health in Newark, Delaware.

Division Planner

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist
healthcare professionals to raise their levels of expertise while fulfilling their
continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the
information and recommendations are accurate and compatible with the standards
generally accepted at the time of publication. The publisher disclaims any
liability, loss or damage incurred as a consequence, directly or indirectly, of
the use and application of any of the contents. Participants are cautioned about
the potential risk of using limited knowledge when integrating new techniques into
practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial
interests are prohibited from distributing or providing access to this activity to
learners.

Table of Contents

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#76840: Maintaining a Healthy Marriage: Implications for Counselors

Review your Transcript to view and print your Certificate of Completion.
Your date of completion will be the date (Pacific Time) the course was electronically
submitted for credit, with no exceptions. Partial credit is not available.

INTRODUCTION

According to the National Center for Health Statistics, there were approximately 2,131,000
marriages in the United States in 2012—and more than 1 million divorces [1]. This means that there is approximately one
divorce for every two marriages. Though the number of divorces has been decreasing since 2000,
so has the number of marriages, keeping the ratio relatively stable. That being said, this
course will not focus on unhealthy marriages or factors that contribute to divorce. Rather, it
will focus on maintaining healthy marriages. From a theoretical perspective, Robert Sternberg
identified the components of two types of long-lasting relationships: those that consist of
companionate love and those that qualified as consummate love [2]. Within this theoretical perspective, this
course will highlight positive communication patterns and affects and the impact self care can
have on maintaining healthy marriages. In addition, it will also draw attention to special
populations in which an apparent lack of research exists. Concrete implications for mental
health professionals working with couples will be discussed throughout the course.

THEORIES OF RELATIONSHIPS

Humans are one of the few organisms that remain with like beings for life. When other organisms give birth, there is a relatively brief period of time during which the mother will nurture and protect her young, but offspring are often on their own shortly after birth. Humans, on the other hand, have more complex long-term relationships. Some people believe that relationships begin at conception, while others believe that relationships begin at birth. Either way, relationships begin long before one has a cognitive understanding of what relationships are.

There have been many theoretical perspectives on the factors that contribute to healthy relationships and marriages. One theoretical perspective posits that long-term relationship health lies within the perception of each individual. Specifically, a source of relationship success is modification of one's own faulty expectations; blaming each other for perceived shortcomings is a source of relationship discord. Some experts propose that healthy relationships are maintained by partners assuming responsibility for challenging the dysfunctional expectations and beliefs they have toward each other [3].

From an external perspective, how people interpret the actions of others contributes to how they behave in their relationships. Also, being aware that even the healthiest relationships have a level of discord and altering or changing behaviors may help the relationship develop further [4,5,6,7].

From an interpersonal perspective, interactions are believed to
naturally develop between couples as the behaviors of one elicit or suppress the behaviors of
the other [8]. More recently, the behaviorally
oriented relationship theory has hypothesized that relationship success or failure is based on
how a couple interacts with one another [9].
According to this perspective, the environmental setting is secondary to how each individual
behaves toward the other.

ESTABLISHING A SOLID FOUNDATION

To achieve a mutually satisfying relationship, it is advantageous to have established a solid foundation from which future relationships are built. This foundation is established via interactions in the family of origin. Parental attachment has been identified as an indicator of early emotional adjustment and later functioning in relationships [10,11,12,13,14,15]. Attachment theory emphasizes the influence parents have over their child's personality development [16]. Consequently, a secure bond results in a secure child who feels comfortable exploring his or her environment. The secure bond further allows the child to become accustomed to, and later involved in, interpersonal relationships. Overall, the literature is consistent in demonstrating that meeting a child's early emotional needs has long-lasting, positive social implications [11,17,18]. Some experts believe the bonds that people form as children become a representation of how future relationships will be approached [19]. If children are secure in their attachments, they have been found to be more open to having attachments later in their lives. Conversely, if children are either attachment anxious or avoidant, they later come to believe that others are also emotionally unavailable.

Erikson's stages of psychosocial development have also been used to identify factors that contribute to healthy adult relationships [20]. Each stage includes a relationship component; however, the emphasis shifts from the biological family in infancy and childhood to establishing a family with a non-biological partner. According to Erikson, a healthy relationship in adulthood is heavily dependent upon the relational health within the family of origin [20].

The conflict associated with the earliest developmental stage
is trust versus mistrust [20]. At this
stage, infants rely on their mother (or other caregiver) to provide comfort. If this is
provided, infants develop a sense of trust, which is considered the first relationship
milestone, providing a physiological understanding of the importance of relationships and
interdependence. This stage of psychosocial development has been replicated in research and
referred to as primary attachment [11].
Primary attachment begins with an infant's initial connection to her or his parent, and its
success helps the child adjust to future relationships. If mistrust develops, this can have
negative consequences that can impact an individual's future relationships [20].

Erikson's second stage of psychosocial development occurs in early childhood (1 to 3 years). During this period, the major conflict is autonomy versus shame. The child begins to physically separate from the parent via gross motor skill development. At the same time, the parent seeks to balance between age-appropriate independence and restricting physical exploration for safety reasons [20]. The proper balance of exploration and caution further solidifies the relational bond if the child feels supported in the quest for independence [11]. The successful resolution of this stage of psychosocial development results in pride and acceptance of the cycle of life. However, shame and doubt can result and be demonstrated by a lack of self-confidence [20].

The resolution of the second stage naturally progresses to the establishment of more independence and relationships outside of the home. Specifically, the child begins formal schooling in the third stage, which is characterized by the conflict of initiative versus guilt [20]. By definition, initiative involves the child feeling comfortable enough to begin establishing goals. Because school is the primary setting for goal establishment and attainment, there are both intellectual and social components. As such, if all previous conflicts have been successfully resolved, further confidence should occur.

School relationships become of further importance as the child enters school age in the fourth developmental stage. The successful resolution of the main conflict of this stage (industry versus inferiority) is heavily dependent on the parental role in the previous stages. In other words, the ability for the now elementary school-age child to socially succeed is achieved via modeling and encouragement of the parent(s) [20].

Stage five, which encompasses adolescence (12 to 18 years of age), places strong emphasis on social relationships [20]. The major conflict during this period is identity versus role confusion. Adolescents are tasked with developing a sense of self and personal identity and staying true to their own selves.

From a healthy relationship perspective, successful
resolution of the main conflict of the next stage (young adulthood), intimacy versus
isolation, is the culmination of all previous stages. According to Erikson, the ability to
establish and maintain close, intimate, and committed relationships during this stage is
central [20]. One's ability to be intimate
with others is heavily dependent on early bonding, established confidence, and goal
achievement, all of which are established in earlier stages. If the conflicts of previous
stages are not successfully resolved, healthy relationships become difficult.

As noted, adequate relationship role models are beneficial in
every stage [11,20]. Research has examined the impact of
marital conflict on child attachment through specific parent and child behaviors [15]. Parental behaviors that have been found to
affect child attachment include how marital problems are communicated and resolved and the
degree of responsibility one assumes during conflict [3,15]. Researchers also
evaluated sensitive behaviors such as promptness and appropriateness of parental responses
to the child.

Several other correlations between attachment behaviors and marital conflict have been identified [15]. Specifically, current marital conflict is negatively correlated with perceived sensitive interactions and positively correlated with perceived parenting attitude with mothers. Also, the degree of attachment between mother and child is correlated with positive interactions. Father-child attachment has been found to be influenced by the degree of marital conflict, which is negatively correlated with both positive parenting attitudes and marital discord. The unfortunate outcome of insecurely attached children is potential lifelong difficulties with interpersonal relationships [15,20,21].

ESTABLISHING AND MAINTAINING ADULT RELATIONSHIPS

Other theories have focused less on the foundation of
attachment and relationship role models and more on present intimate relationships. Despite
marriages and long-term relationships having existed for thousands of years, it was not
until Sternberg wrote about the three components of love that essential components of
healthy relationships were delineated [2].
According to Sternberg and his Triarchic Theory of Relationships, a healthy long-term
relationship is comprised of adequate levels of intimacy, passion, and commitment [2]. The level of each of these components
fluctuates depending on the type and duration of the relationship. That being said, certain
types of relationships are more likely to be healthy and span time. Companionate love is a
relationship that is high in both intimacy and commitment but low in passion. Although
physical attraction, or passion, may have decreased, the couple will likely stay together in
the long term. The other types of relationships are liking (only intimacy), empty love (only
commitment), infatuation (only passion), fatuous love (passion and commitment), and romantic
love (intimacy and passion); these types are less likely to be lasting unless they evolve.
According to Sternberg, the healthiest relationship is one of consummate love, in which
intimacy, passion, and commitment are equally strong [2]. However, consummate love is not the end of the journey. Indeed, to have
a relationship of consummate love is one of attainment and maintenance. A relationship of
consummate love acknowledges commitment while maintaining positive emotions and being
mindful of how one communicates during conflict [2,22].

If an individual does not perceive the healthiest of attachments from his or her family of origin, companionate or consummate types of relationships are still achievable [2]. To this end, attachment-based family therapy and attachment-focused group therapy may be helpful [19]. The latter is a curriculum-based intervention for men and women considered to be insecurely attached. In the group process, participants address maladaptive beliefs about relationships and relationship role models; it is important to discuss role models as they are believed to establish the basis for future romantic partners [20,21]. The group may work toward an understanding of relationship insecurity, and after this is achieved, concrete skills training and interventions may be introduced. In some studies, the group format was seen as more beneficial than individual sessions as it doubled as a source of support and a method to have understood the how others have functioned in relationships. Throughout the group process, trust and communication with others is also established [19,23].

Another intervention for developing successful relationships
despite being insecurely attached is attachment-based family therapy. Although this
treatment was originally designed for families and individuals who experienced adolescent
depression and suicide, it has also been suggested for fostering healthy relationships [19,24]. Attachment-based family therapy assists group participants in
processing past and present relationship conflicts that reinforce mistrust and insecurity.
Therapy can then move into individual competency and independence. The goal of this type of
therapy is to decrease isolation, increase self-esteem, and instill relationship hopefulness
[19].

THE INDIVIDUAL EXPERIENCE AND HEALTHY RELATIONSHIPS

INTERNAL EMOTIONAL EXPERIENCES AND HEALTHY RELATIONSHIPS

Fostering a healthy marriage or long-term relationship can be akin to flying a plane. In order for a plane to reach the necessary altitude, effort and work are necessary. It requires maintenance before and after each flight and a crew to support the pilot in order for the plane to take off. When the plane is in the air and has reached its altitude, the work does not stop; it takes constant monitoring to make sure a plane flies smoothly and stays in the air. The start of any relationship also requires work and effort, and when a relationship is stabilized, the work does not stop. There is no "autopilot" in relationships; monitoring for checks and balances is required. Even seemingly stable relationships are at risk to dissolve without the presence of support and positive emotions within the couple [22].

Historically, the majority of research on couples has focused
on conflict as the primary, and sometimes sole, predictor of relationship outcomes [7]. However, research has also shown that
approaching a relationship from a positive affective state is important, even during
conflict. Neurologic studies indicate that approaches to tasks or events are influenced by a
positive affective state [25]. For example,
a frustrated or sad member of a couple may interpret seemingly neutral communication and
conflict as his or her own shortcoming. Positive affect is instrumental in minimizing the
magnitude and duration of conflict. This has been illustrated in studies of couples engaged
in a positive, approach-oriented interaction task [7].

A study involving 119 newlywed heterosexual couples assessed
their approach to conflict six months and again one year after their weddings [7]. For the initial meeting, couples
individually completed measures focused on their overall perception of the relationship.
Then, the couples were asked to briefly discuss an issue as if they were at home.
Participants completed measures of how each felt after the discussion. Finally, the couples
were separated and asked to focus on their positive feelings toward their partner and then
reunited to discuss these feelings. After the first session, researchers categorized the
couples as either approaching conflict from a positive place of affection or from a negative
place of contempt and predicted that those with a positive approach would perceive more
marital satisfaction and be less likely to divorce. After one year, approaching conflict
from a positive place had a positive correlation with marital satisfaction and a negative
correlation with divorce [7]. However, there
was a subjective threshold in that the magnitude of the conflict was a consideration. In
other words, approaching an abusive relationship from a place of forgiveness, optimistic
expectations, positive thoughts, and kindness was more harmful than helpful [26].

In some cases, approaching communication from a positive place can be difficult in couple interactions. For instance, a dynamic may develop whereby one partner assumes a place of psychological shelter when interpreting how responsive the other is to his or her needs [6]. In order to avoid the anticipated risk of rejection, one partner appears emotionally closed off from the other. This results in a dilemma: emotional closeness is a necessity for a healthy relationship, but this is difficult or impossible when one partner is afraid of being rejected and/or being emotionally discounted [6,27].

To avoid developing this dynamic, couples are encouraged to foster a foundation of emotional wellness in their relationship. In a 2013 study, couples participated in an online intervention designed to increase relationship excitement [28]. Preintervention measures assessed subjective levels of relationship excitement, relationship satisfaction, affective states experienced in the previous week, and the amount of time spent on exciting activities. A correlation was noted between excitement in the relationship and the experience of positive emotions. As a proactive method to maintain relationship health, researchers suggested that couples be encouraged to routinely find ways to increase levels of excitement within their relationship [28]. Mental health counselors are also encouraged to talk to their clients about the importance of incorporating excitement and the present level of excitement in their relationship. Within this particular study, excitement was categorized as adventurous, passionate, sexual, exciting, interesting, playful, romantic, or spontaneous.

THE IMPACT OF THOUGHTS ON RELATIONSHIPS

A successful relationship can be more than just the
interaction between two partners. Specifically, factors such as genetics and self-talk also
play a role, and relationship success is often heavily dependent on the perceptions of each
individual [3,15,16,29]. For example,
placing blame is a source of relationship discord, while focusing on the overall strengths
of one's partner is a factor in relationship success [3]. This can be complicated by each member of the couple's unique
perspective, perceptions, and interpretations of the same situation [4,5]. From an internal perspective, an individual in a healthy relationship
assumes responsibility for modifying his or her dysfunctional expectations and beliefs. From
an external perspective, how one interprets the actions of the other, likely based on causal
inferences from many sources, influences how she or he behaves [30].

As noted, many philosophies of emotions agree that thoughts and feelings influence behaviors [31]. Beck is more linear in his approach and theorizes that initial thoughts influence emotions, which subsequently influence behaviors and resultant consequences [3]. In healthy relationships, automatic thoughts are less likely based on a cue-interaction effect—a quick judgment based on an intense emotional situation—and more likely to be based on moderate cues in the relationship [30].

Incorporating cognitive restructuring techniques into cognitive-behavioral therapy (CBT) can improve relationships by addressing cue-interaction effects [3,30,32]. From a CBT perspective, cognitive restructuring techniques can alleviate unpleasant feelings activated by negative automatic thoughts. While individuals have limited control over automatic thoughts, they do have control in how they responded to such thoughts. Some couples benefit from counseling and learning skills to positively respond to negative cognitions in order to minimize the intensity of the resulting unpleasant emotions. Cognitive restructuring uses logic and reason to replace the distorted thoughts that can intensify heated emotions. It also involves realistically examining conflict from multiple perspectives, as opposed to solely placing blame on one's partner [3,32]. Couples may be taught to see their environment in a similar fashion during conflict, which can increase adaptive communication [5].

Although research has supported the effectiveness of cognitive restructuring alone, it can be enhanced with the selected use of other techniques [32]. In one study, researchers found success after six months with restructuring integrated with behavioral marital therapy, but this was not the case when restructuring, behavioral marital therapy, and emotional expressive training were implemented together. They reasoned that limiting the number of interventions allowed couples more concentrated time to learn and apply restructuring. For the purpose of the study, behavior marital therapy consisted of expressive communication techniques to solve problems, and emotional expressive training involved expressing emotions and receptive, active listening.

From a more global perspective of CBT, clients may benefit from interventions that address the application of thoughts and how they nurture or inhibit growth in a relationship. For example, approaching a relationship in a cognitively positive place, as per the CBT model, may result in the person behaving in ways that promote relationship growth [3,6]. Specific examples include cognitively highlighting the strengths of the partner and responding, as opposed to reacting, to emotionally tense situations [6].

PROMOTING RELATIONAL HEALTH

As noted, Beck has proposed that healthy relationships begin with each individual assuming responsibility for modifying dysfunctional expectations and beliefs [3]. This becomes the basis of how each member of a couple behaves toward his or her partner. The most apparent behavior in couples was how they communicate with one another. Communication standards are developed over time and become a stable, almost fixed, pattern in a relationship. Such a fixed pattern gives insight into the overall quality of the relationship and may also reflect cultural differences [9,33,34]. In one study, Chinese and American couples demonstrated an equal amount of positive behaviors, such as compliments, laughter, and active listening, but the Chinese couples demonstrated more negative communicative behaviors, including sarcasm, interruptions, and blaming. With communication as a contributing factor, the Chinese couples reported lower levels of relationship satisfaction [34].

Most people have a general idea of how they communicate with their significant others. However, few are aware of the subtleties within their overall communication patterns, and it is the subtleties that help or hurt the relationship. Simmons, Gordon, and Chambless explored spousal use of pronouns while problem solving in a sample of outpatient mental health clients with a spouse diagnosed with an anxiety-related disorder [35]. Each couple was recorded talking for 10 minutes about a source of conflict in their relationship. Many of the couples spoke about conflicts that arose from the anxiety disorders; other topics were more general in nature and included how household tasks were divided. Each couple was encouraged to come to some sort of resolution to the conflict.

Overall, the researchers concluded that conflict resolution including the use of shared pronouns (e.g., we, us) was correlated with a more positive affect during conflict. On the other hand, use of singular pronouns (e.g., I, you) was interpreted as blaming and its use was correlated with negative interactions. These easily overlooked plural pronouns are believed to be a subtle statement of commitment and are considered both a sign of a healthy relationship and an indication of successful development [2,20]. These findings have been echoed in other research that suggest it is not so much the issues within a marriage as it is how issues are communicated that contribute to longevity and happiness [9]. Within a relationship, the feeling of commitment is instrumental for nurturing connectedness to a partner [6].

In one study, a time-limited couple enrichment program designed to improve communication
showed a lasting benefit at three-week follow-up, although there was no follow-up to determine
longer term benefit [36]. In this program,
couples were encouraged to monitor their positive and negative interactions. Researchers found
that the value of any conflict was dismissed if positive interactions occurred more often and
more consistently.

Non-verbal listening is another positive communication factor. For example, individuals display a visceral reaction with the establishment of eye contact with their partner. Eye contact is generally perceived as attentiveness and engagement [37].

The Prevention and Relationship Enhancement Program (PREP), a therapy-based intervention,
was developed to improve relationship functioning, and much of the program is based on how one
partner communicates with the other [27]. A
study of the effectiveness of a weekend PREP program examined 39 married, heterosexual couples
in a small, southeastern university town [38].
For one weekend per year, communication skills were taught via lectures and practiced with
couples privately. The practices were based on expressing opinions and emotions on real-life
relationship issues. Researchers found that, overall, couples did alter their communication
patterns post-intervention, and some gender-specific correlations were noted. Among the men,
their perception of adaptive communication created the belief that there would be decreased
stress in the future. However, the changes in communication for the women led to a belief that
future distress would occur. This finding was reconstructed as positive in that maladaptive
communication was the result of avoidance. After the intervention, couples were more likely to
approach and address conflicts that were previously avoided. Opinions and disagreements were
more openly expressed in the long term, and this benefited the couple. More assertive
communication eventually decreased the likelihood of avoidance through the use of perceptual
filters.

The concept of filters was outlined in the original PREP
program. According to PREP, filters develop from a gradual build-up of uncommunicated
interpretations [4,5,27]. Several types of filters were identified: distractors, emotional arousal,
need for self-protection, differences in style, and acquired beliefs (e.g., cultural, family
of origin) [27]. Distractors result when one
partner is only partially attentive while the other is speaking. Within the environmental
dynamics of daily life, there are many internal and external distractors, including children,
television, and work. Couples who communicate adaptively tend to provide their undivided
attention to each other.

Communication is also filtered through the emotional state of the listener [25,27,39]. Adaptive communicators are able to accurately survey the emotional state of the other. Filters are minimized during less stressful times, while defenses and interpretations are maximized when a listener is stressed and/or frustrated [27].

As an aside, this is where the value of self care is paramount, as the impact of stress and frustration is exacerbated by lifestyle factors such as lack of sleep, lack of exercise, and poor dietary choices [7,27,31]. As a good self-care practice, each member of the couple should monitor his or her respective stress levels and mood. Even seemingly healthy relationships can be compromised when coping resources are depleted. In one study, wives in a married dyad that qualified as depressed-distressed typically misunderstood their husbands and felt misunderstood by their husbands when communicating [9]. Conversely, couples who qualified as non-distressed felt that communication was clear and conflict resulted in quicker recovery when compared with the depressed-distressed participants. Overall, non-distressed married communicators were believed to have better communication skills and be less likely to misinterpret the communication of their spouse [39].

In addition to the aforementioned filters, PREP cautions against the development of additional filters. Within the framework of CBT, PREP categorizes beliefs and expectations as a communication filter [3,27]. Couples who communicate effectively were aware of, or minimize, "mind reading." Negative interpretations are often based on what was not said or the individual trying to guess the meaning behind what her or his partner said.

In addition, couples with effective communication tend to employ similar communication styles [3,27]. If couples have different communication styles (e.g., one more verbal and one less verbal), adaptive communicators are able to be empathic to this and accept it as a factor in their relationship.

Finally, healthy communicators allow each other to be vulnerable. In some couples, assuming
a more guarded stance is seen as a defense against potential hurt and rejection. Some couples
may have inhibited communication in order to avoid anticipated hurt feelings [27].

HEALTHY RELATIONSHIPS AND SPECIAL POPULATIONS

The fact that the majority of research on couples focuses on
conflict as the primary or sole predictor of relationship outcomes is a deficiency in
relationship research [7]. Another shortcoming
of relationship research is that much of it has been based upon a younger, white population
[22,33]. As society has evolved, so have the difficulties in concretely
identifying cultures, especially as they become increasingly blended [4]. Evidence-based therapeutic interventions for
couples tend to be more appropriate for middle-class white clients than those from lower
socioeconomic statuses and other cultures [9,33]. Mental health clinicians are at risk
for making decisions based on stereotypes when working with certain populations, and this can
hinder the effectiveness of therapeutic interventions [4].

As such, it is important to consider the cultural implications of what might be defined as a healthy relationship when working with a couple. From the earliest of relationships, studies have noted differences in how children from under-researched populations attach to their parents. For instance, in a study of parental attachment, gender differences, and the influence of race in a sample of African American and white college students, assessments were used to rate perceived parental bond, competencies in relationships, and the overall emotional stability of the participants [29]. The researchers found some differences in the way African American and white participants perceived attachment [29]. If attachment bonds were strong, the relational competencies of the participants were strong, regardless of race. However, definitions of attachment differed between races. While both groups reported that overall perceived parental relationships were stronger for fathers, the degree of attachment was stronger in the African American population compared with the white group. This may have been indicative of how attachment is evolving, as past literature and theory cited more of a maternal bond [11,13,16,40].

From a therapeutic perspective, working with special populations in established, loving relationships poses some challenges. Even the results of certain relationship studies with special populations may be suspect. Research findings should be cautiously interpreted due to the possibility that participants act differently during the study than in their natural settings [33].

Despite the lack of research focusing on relationships in
specific populations, it is still important that clinicians develop cultural competence. This
involves being self-aware of cultural differences and adapting accordingly to clients [41]. Cultural competence also consists of
therapists seeing the individual within his or her culture, as opposed to seeing the culture
and then the individual [4]. From a more
global perspective, practitioners should consider how marital behaviors are displayed in a
collectivistic (e.g., Chinese), as opposed to individualistic (e.g., American), cultures.
Couples from individualistic cultures tend to be more open with expressions of affection,
while those from a collectivistic cultures are not [34].

When relationship research is conducted involving
racial/ethnic and sexual/gender minority populations, it often lacks the necessary long-term
data to establish more specific differences [9]. For example, though some literature examines the relationship dynamics within gay and
lesbian couples, reaching conclusions is difficult because of the likelihood of
under-reporting [5]. In general, it appears
that gay and lesbian couples have similar conflicts to heterosexual couples, but there are
differences in how conflicts are resolved. Heterosexual couples tend to rely on family members
for support, while gay and lesbian couples rely more on close friends. Other populations
rarely studied in the literature, such as those from lower socioeconomic statuses, may have
different types of conflict or conflict resolution styles compared with majority populations,
and it is important to ascertain the specific hardships of these populations and be aware of
how they are communicated [9].

Overall, there are multifaceted considerations when working with special populations. Some clients may identify themselves by numerous cultures and races, which should be acknowledged and incorporated into any interventions used. One way of ensuring this occurs is through ethnographic interviewing, during which the counselor asks open-ended questions in an effort to ascertain the unique cultural perspective that the client assumes [4].

While culture and ethnicity play a role in a person's identity, it does not necessarily define that person. In addition to considering the cultural perspective of the person, mental health professionals should be mindful of their own perspective, monitor their own worldview, and kept abreast of culturally based literature [4].

CONCLUSION

Although challenging, fostering a healthy relationship can be a rewarding experience. There is a wealth of theories and interventions for mental health clinicians to work from, but every couple is different. As such, finding specific and effective interventions for couples can be difficult. Attention should be given to the family of origin and culture of both members of the couple.

It can also be challenging for the couple to strengthen their relationship, as fixed patterns of behavior are difficult to alter and many couples default to the dynamics that initially brought them into counseling. Effective interventions applied to a couple that is willing to work toward harmony can make significant strides. It is the hope that, with the help of this course, working with couples can evolve from reactive, maladaptive interactions to proactive, adaptive interactions that foster the continued health of the relationship.

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28. Coulter K, Malouff JM. Effects of an intervention designed to enhance romantic relationship excitement: a randomized-control trial. Couple and Family Psychology: Research and Practice. 2013;2(1):34-44.

29. Rice KG, Cunningham TJ, Young MB. Attachment to parents, social competence, and emotional well-being: a comparison of Black and White late adolescents. Journal of Counseling Psychology. 1997;44(1):89-101.

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